Reflex Sympathetic Dystrophy Patients Research Articles

Electroacupuncture for Reflex Sympathetic Dystrophy after Stroke: A Meta-Analysis

Background: Reflex sympathetic dystrophy (RSD) is the common complication among stroke and cerebral injury patients, which is lack of safe and effective treatment. Electroacupuncture (EA) may potentially be a reliably therapy, but the evidence is insufficiency. Methods: Cochrane Library, MEDLINE, Embase, Chinese National Knowledge Infrastructure, Wan Fang Data, the Chinese Biology Medicine disc, etc., were searched, until July 20, 2018. We included random control trials that contrast EA with conventional rehabilitation therapy for the treatment of RSD. Main outcomes were visual analog scale score and Fugl-Meyer upper limb motor function scoring scale, other outcomes such as Barthel index, and hand swelling score were also collected. Data in included studies were extracted into an excel and pooled by Stata/MP 14.1. Results: We incorporated 13 studies involving 1040 RSD patients and outcomes were from 2 to 6 weeks' follow-up. The analgesic effect between 2 groups had statistically significant difference (weighted mean difference [WMD] = −1.122, 95% confidence interval [CI] [−1.682 to −.562], P = .000], a statistical difference existed in improving dysfunction between 2 groups: (WMD = 6.039, 95% CI [2.231−.916], P = .000). EA groups had a better effect on improving activities of daily life abilities (WMD = 12.170, 95% CI [6.657−17.682], P < .00011] and better detumescence effect (WMD = −.800, 95% CI [−1.972 to −.212], P = .000] contrast to conventional rehabilitation therapy. Conclusions: This meta-analysis supports that EA has a positive effect on alleviating pain, improving limb dysfunction, and promoting activities of daily living. On account of moderate-quality random control trials and high heterogeneity, further high-quality studies are imperative to optimize the EA treatment program.

Mechanism of post-stroke reflex sympathetic dystrophy:study with needle electromyography

To explore the mechanism of post-stroke reflex sympathetic dystrophy (RSD) patients electromyographic abnormality and confirm its clinical value. Fifty patients with first-onset stroke, aged 33 - 78, including 30 with RSD and 20 without RSD, underwent needle electromyography (EMG) to test the nerve conduction velocity (NCV) and sensory nerve conduction velocity (SCV) of bilateral median nerves, and the number and position of spontaneous EMG activity of bilateral short abductor muscles of thumb and abductor muscles little finger. The median nerve compound muscle action potential (CMAP) amplitude of the affected upper extremities of the RSD group was 8.6 mV +/- 2.9 mV, significantly lower than that of the non-RSD group (13.2 mV +/- 4.6 mV, P < 0.01). The incidence of spontaneous electrical potential of the RSD group was 100%; significantly higher than hat of the non-RSD group (65%, P < 0.001). The quantity of spontaneous EMG activity on the short abductor muscles of thumb and abductor muscles little finger was increased in the RSD group (P < 0.01). The motor nerve conduction velocity and electrophysiological presentation of sensory nerve of these 2 groups were all normal and without significant differences between them. Partial axonal degeneration occurs on the distal motor never fibers of the affected upper extremity of the RSD patients, which may be related to subsequent peripheral nerve injury after central nerve system impairment.

Determination of inflammation of reflex sympathetic dystrophy at early stages with Tc-99m HIG scintigraphy: preliminary results

The pathogenesis of reflex sympathetic dystrophy (RSD) is not completely understood. However, an excessive regional inflammation, sensitization of primary somatosensory afferents, and sensitization of spinal neurons are considered to have a role in the pathogenesis of RSD. The underlying pathophysiology relating the clinical picture may help to determine the pharmacotherapeutic approach for an individual patient. Scintigraphy using radiolabelled human polyclonal non-specific immunoglobulin (HIG) has been recognized as a useful tool for the localization of inflammatory disorders. Thirty-six consecutive RSD patients associated with hemiplegia were included in this study. All the patients in this study had three phases bone scan and Tc-99m HIG scintigraphy. On admission, of 36 patients with positive bone scan, 30 had positive Tc-99m HIG scan. All the patients were symptomatic at the time of bone scanning. On the contrary, 24 out of 36 patients subsequently became asymptomatic at an 8-month re-evaluation period. Tc-99m HIG scintigraphy is a non-invasive complementary method for the determination of ongoing inflammatory reactions which also aids the clinicians to predict the response to anti-inflammatory therapy at the very early phase of RSD associated with hemiplegia. This preliminary study may be a source of inspiration for further studies with larger series and longer follow-up .

The predictive value of additional late blood pool imaging to the three-phase bone scan in the diagnosis of reflex sympathetic dystrophy in hemiplegic patients

Reflex sympathetic dystrophy (RSD) is a relative common sequel after hemiplegia. The diagnosis of RSD in hemiplegic patients presents difficult clinical problems, as the symptoms and signs of RSD are not specific and RSD may be due to reasons other than hemiplegia. Bone scintigraphy has been routinely used for the diagnosis of RSD; however, the optimal acquisition protocols, diagnostic patterns and the utility of quantitation are controversial. This prospective study was conducted to demonstrate the higher predictive value of an additional late blood pool image to the three-phase bone scan compared to the regular three-phase bone scans in RSD patients associated with hemiplegia. Thirty-four RSD patients were enrolled into the study. Bone scans according to the new protocol were obtained for all patients. Those patients with either negative or positive bone scans with no evidence of RSD were followed for 6 months. The patients had positive bone scan findings and were symptomatic at the time of the study. Of these, seven patients (58.3%) subsequently became symptomatic and five patients (41.7%) remained asymptomatic at 6 months. None of the patients with negative bone scans had symptoms of RSD on presentation except one case. We conclude that the addition of a late blood pool image increases the predictive value and has an impact on initiating early treatment in asymptomatic patients.

A NEW CLINICAL SEVERITY SCORING SYSTEM FOR REFLEX SYMPATHETIC DYSTROPHY OF THE UPPER LIMB

A scoring system for the clinical severity of reflex sympathetic dystrophy (RSD) is proposed. The following signs and symptoms were considered to be significant: pain, reduction of finger flexion, swelling, temperature changes, discolouration, sensory disturbances, shoulder pain and loss of movement, increased sweating, and hair/nail growth changes. One point was assigned for strong expression of most of these features, half a point for moderate expression and no point if the feature was absent. A total score of 4 points was assumed, empirically, to indicate a mild degree of RSD, and the maximum score of 10 to indicate the most severe form of RSD. One hundred and forty-six patients with RSD of the hand were classified according to this system. Seventy-four patients (51%) had a score of 4–6, 51 patients (35%) a score of 6.5–8, and 21 patients (14%) a score of 8.5–10. Use of this system will allow more precise analysis of RSD patients and facilitate comparisons between studies.

Reflex sympathetic dystrophy of the left hand and motor impairments of the unaffected right hand: Impaired central motor processing?

Ribbers GM, Mulder T, Geurts AC, den Otter RA. Reflex sympathetic dystrophy of the left hand and motor impairments of the unaffected right hand: impaired central motor processing? Arch Phys Med Rehabil 2002;83:81-5. Objective: To test whether central motor processing can be impaired in chronic reflex sympathetic dystrophy (RSD). Design: Experimental 2-group analysis. Setting: Tertiary care center in the Netherlands. Participants: Five patients with stage 3 RSD of the left forearm, free of symptoms and complaints in the right forearm; and 10 healthy control subjects. Intervention: On a digitizer, RSD patients and controls had to draw 3 sequences of graphemes of different complexity with their (unaffected) dominant right hand. The drawing tracks were segmented in time periods between points of velocity minima of the pen tip. Main Outcome Measures: Mean velocity, coefficients of variation of both length and movement time per segment, and mean intersegmental pausing time were calculated for each sequence. Results: A repeated-measures analysis of variance by using the multivariate method yielded a 35% lower mean velocity (F1,13 = 5.83, P =.031), a 110% larger segment length variability (F1,13 = 9.72, P =.008) and a 60% larger variability of movement time per segment (F1,13 = 5.78, P =.032) in RSD patients. No group difference was found for intersegmental pausing time or any interaction effect with the type of task. Conclusion: Patients with chronic RSD have a normal ability to preprogram sequential movements of their unaffected hand; but with impaired temporospatial coding and movement execution. We concluded that cortical mechanisms may be involved in motor impairments in patients with chronic RSD. © 2002 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Neurophysiologic aspects of patients with generalized or multifocal tonic dystonia of reflex sympathetic dystrophy.

Reflex sympathetic dystrophy (RSD) is a syndrome dominated by sensory, autonomic, and motor features of the extremities. In this study, 10 severely affected RSD patients who progressed to multifocal or generalized tonic dystonia underwent H-reflex evaluation, needle electromyography (EMG), polysomnography, somatosensory evoked potentials, and transcranial magnetic stimulation. H-reflex evaluation revealed an impaired vibratory inhibition of the H-reflex and a higher facilitation peak in the recovery curve between 200 to 350 msec. Needle EMG revealed an impaired reciprocal inhibition, and many patients were unable to alter the amount of muscle activity voluntarily. Evaluations of the stretch reflex showed a markedly decreased threshold and abnormal responses to tonic and phasic changes. Polysomnography performed in five patients revealed no abnormal EMG activity during nonrapid eye movement and rapid eye movement sleep, but EEG arousal phenomena provoked abnormally high and brief bursts of surface EMG activity in all registered muscle groups. Somatosensory evoked potentials and transcranial magnetic stimulation were normal. Taken together, the findings in these patients with tonic dystonia of RSD are in accordance with an impairment of inhibitory interneuronal circuits at the level of the brainstem or spinal cord.

Strain and psychological distress among informal supporters of reflex sympathetic dystrophy patients

Purpose : A study to investigate strain and psychiatric morbidity in informal caregivers of patients with reflex sympathetic dystrophy (RSD). Method : Fifty one caregivers of RSD patients in the community, identified from a support group in Leeds or a conference in Eastbourne completed standardized questionnaire measures of strain, mood, adjustment, positive and negative affectivity and social support. Results : Fifty seven percent of caregivers experienced significant strain and 53% had poor mood. Adjusting for age and gender, partial correlations showed that the experience of strain in caregivers was associated with poor mood, poor psychological adjustment to the patient's illness, high levels of negative affectivity, increased handicap and disability of the patient. Conclusions : A high proportion of caregivers of RSD patients experience poor mood and significant levels of strain. Caregivers who are poorly adjusted to the illness experience the most strain. These findings suggest a need for intervention to alleviate the negative impacts of caregiving and facilitate adjustment.

Reflex sympathetic dystrophy: Is the immune system involved?

Objective: Evaluation of immune system function in patients with reflex sympathetic dystrophy (RSD). Design: Survey on blood samples obtained from RSD patients and from a randomly selected control group. The lymphocyte populations (T, B, NK cells), and the activated T cells (CD25, and HLA-Dr-positive CD4 and CD8 cells) were analyzed by flow cytometry with dual-color direct immunofluorescence after whole-blood lysis. Clinical chemistry parameters were analyzed in additional serum samples. Setting: Tertiary care center (outpatient rehabilitation clinic). Subjects: Thirteen patients (nine women) with RSD and a control group of 21 healthy individuals. Main Outcome Measures: The results of the flow cytometry analysis of RSD patients were related to those of the control subjects. Means were analyzed, and confidence intervals for differences of the means were calculated. The means of the clinical chemical analysis were related to local reference values. Results: The flow cytometry analysis did not differ between RSD patients and healthy controls. Although in some patients an individual parameter of clinical chemical analysis differed from its reference value, all of the mean values were within reference limits. Stratification on medications with immunomodulatory effects and on probability of a definite diagnosis of RSD had no influence on the results. Conclusion: No association between immunologic indices and RSD was found. This finding is relevant, because recent theories stress that it is not the sympathetic nervous sytem but a local inflammatory reaction that is fundamental in the pathogenesis of RSD. The results of this study do not support this theory.

Relationship between impairments, disability and handicap in reflex sympathetic dystrophy patients: a long-term follow-up study.

To determine the relationship between impairments, disability and handicap in reflex sympathetic dystrophy (RSD) patients. A long-term follow-up study of upper extremity RSD patients. A university hospital. Sixty-five patients, 3-9 years (mean interval 5.5 years) after RSD of the upper extremity (mean age 50.2 years). Impairments: range of motion, moving two point discrimination, muscle strength of the hand and pain were measured. Disability was assessed with the Groningen Activity Restriction Scale (GARS) and handicap was assessed with three subscales (social functioning, role limitations due to physical problems and role limitations due to emotional problems) of the RAND-36. After RSD of the upper extremity, 62% of the patients are limited in activities of daily living (ADL) and/or instrumental ADL (IADL). Pain and restrictions in forward flexion of the shoulder, thumb opposition and grip strength are the most important impairments limiting ADL and IADL. Patients with limitations in ADL and IADL are significantly more handicapped than patients without limitations. Pain is the most important factor contributing to handicap. The relationship between impairments and disability and between disability and handicap in RSD patients is weak to moderate. Pain is the most important factor leading to disability and handicap.

Impairment level sumscore in reflex sympathetic dystrophy of one upper extremity

Objectives: To construct a set of instruments to measure the level of impairment in reflex sympathetic dystrophy (RSD), to convert the scores for each instrument into one score and to derive a compounded impairment level sumscore (ISS), and to evaluate reliability, validity, and responsiveness of the ISS. Data Sources and Extraction: Literature search in Medline (1985 to 1995), non-Medline journals, and references from these reports for measurement parameters and suitable, reliable, responsive, and validated instruments. Data Synthesis: Four measurement parameters (pain, active range of motion, temperature, and volume) and five measurement instruments were chosen to construct the ISS. All outcomes were converted into one score, resulting in an addable score. Results: Forty-five patients with RSD of one upper extremity were evaluated. As expected for this heterogeneous index, the internal consistency of the ISS was poor to moderate. The ISS seemed to have content and concurrent validity. The responsiveness of the ISS was adequate. Conclusions: A multicomponent test was constructed to map alterations in the level of impairment in RSD patients. Each of the parameter scores could be translated into a uniform score. Adding the scores yielded the ISS.

Variation in measurements of range of motion: a study in reflex sympathetic dystrophy patients.

To quantify the amount of variation attributed to different sources of variation in measurement results of upper extremity range of motion, and to estimate the smallest detectable difference (SDD) between measurements in reflex sympathetic dystrophy (RSD) patients. Two observers each measured in two sessions the range of motion of several upper extremity joints of RSD patients participating in an outcome study. Department of Rehabilitation of a university hospital. Twenty-nine upper extremity RSD patients. The range of motion of forward flexion and external rotation of the shoulder, extension, flexion and supination of the elbow, palmar, dorsiflexion and ulnar, radial deviation of the wrist of affected and nonaffected sides, using a two-armed goniometer and an inclinometer. The measurement results were analysed using an analysis of variance according to the generalizability theory. The results indicate that observer and patient-observer were important sources of variation. The random error was the most important source of variation. Averaged over all ranges of motion the observer contributed 3.9% to the total variation, patient-observer interactions contributed 5.2% and the random error 20.3%. The SDD was smallest for elbow flexion, 7.1 degrees and 9.6 degrees and was largest for external rotation of the shoulder, 24.8 degrees and 28.7 degrees. The SDD was smaller for the nonaffected side as compared to the affected side for the majority of ranges of motion except elbow extension, wrist dorsiflexion, and radial and ulnar deviation. Clinically, our results indicate that range-of-motion measurements in RSD patients are subject to considerable variation and indicate that results of medical examinations in order to assess disability on the basis of range-of-motion measurements are subject to the same variation.

Severe complications of reflex sympathetic dystrophy: Infection, ulcers, chronic edema, dystonia, and myoclonus

Objective: To determine the prevalence, type of complication, predisposing factors, and treatment for severe complications in a population of reflex sympathetic dystrophy (RSD) patients. Design: Retrospective analysis of the data from RSD patients collected over a 12-year period, to investigate the involvement of predisposing factors in an RSD population without severe complications compared with an RSD population with severe complications. Setting: Outpatient clinic of a department of surgery of a university hospital. Patients: A total of 1,006 patients with the diagnosis of RSD established according to prospectively defined criteria. Main Outcome Measures: The signs and symptoms of every RSD patient who visited the department were prospectively documented in the medical history; these data were retrospectively analyzed with special regard to RSD with severe complications-infection, ulcers, chronic edema, dystonia, and/or myoclonus for prevalence, type of complication, and treatment. Results: Seventy-four RSD patients who were mostly young and female developed severe complications. More than one complication occurred in 91% of the affected extremities. Severe complications developed more frequently in the lower extremity (65%). In patients in whom the acute RSD started with a decreased skin temperature of the affected extremity, severe complications developed significantly more often than in acute RSD patients with a warm skin temperature of the extremity from the onset of the disease ( p < .001). Conclusions: It is important to recognize “cold” RSD immediately at the onset of the disease because this group of RSD patients has a higher risk of developing a severe complication, mostly followed by a severe disability that is resistant to therapy.

Variation in measurements of grip strength. A study in reflex sympathetic dystrophy patients.

The clinical picture of reflex sympathetic dystrophy (RSD) is characterized by a combination of the triad: autonomic, motor and sensory changes. In this study, the grip strength is measured in 29 upper extremity RSD patients. We used the generalizability theory to assess the extent of the disagreement or differences (errors in measurement) within or between observers and interactions between observer-session and repetition of the measurements. The aims of our study were to determine the different sources of variation in grip strength tests and the smallest detectable differences (SDD) as well as the reliability of upper extremity grip strength tests in RSD patients. The main sources of variation of measurement errors were observer, patient/observer interactions and patient/session/observer interaction and a random source. We found that the generalizability theory is useful for estimating the sources of measurement error. Clinical examinations for muscle strength measurements, as a part of a total clinical examination, for example for a disability payment or worker's compensation in case of RSD patients should be done by more than one observer in more than one session and more than once.

Reflex sympathetic dystrophy of the upper extremity—a 5.5-year follow-up

The aim of this retrospective and long-term follow-up study was to identify impairments resulting from reflex sympathetic dystrophy (RSD) of the upper extremity and to analyze the relationship between impairment and disability in RSD patients. The study group consisted of a referred sample of 65 RSD patients, with clinical signs in the upper extremity. RSD developed after fractures of the wrist or hand in 29 patients or after a carpal tunnel release in 9 patients. The mean interval between the RSD diagnosis and our evaluation was 5.5 (3-9) years (SD = 0.8). The main outcome measurements were the impairments assessed by standard physical examination. ADL and pain were quantified with a visual analogue scale (VAS). Pain was evaluated immediately before and after the physical examination and the perceived pain was determined in the week before the examination. Significant differences in impairments were found between the affected and the unaffected sides (p < 0.05). According to the AMA-guides, the impairments did not lead to disabilities. Significant correlations were found between VAS-ADL and VAS-pain in the last week prior to evaluation and full fist grip-strength. Pain seems to be the most disabling effect.

Reflex sympathetic dystrophy of the upper extremity—a 5.5-year follow-up

The aim of this retrospective long-term follow-up study was to describe the psychosocial aspects, such as social life events (SLE), around the causative event of reflex sympathetic dystrophy (RSD) and the psychological history of 65 patients, 3-9 years after RSD of the upper extremity. General health and long-term changes in occupation were assessed by means of a general health questionnaire (RAND-36) and a structured interview, respectively. SLE, with a life-change unit rate more than 35, was present in 32 patients. A psychological (or psychiatric) history was found in 22 patients. In total, 60% of the patients had a SLE and/or a psychological history. The pain scores of the RAND-36 among RSD patients differed significantly from those of the control group. 17 patients changed occupation after RSD. Nearly 30% of the patients had to stop work for more than one year. The results show a high coincidence between RSD and associated psychosocial disorders and this may play a role in intensifying and prolonging the symptomatology of RSD.

Psychological dysfunction in patients with reflex sympathetic dystrophy

Patients with reflex sympathetic dystrophy (RSD) often present with pain and disability that cannot be explained on the basis of objective physical findings. This has led some to speculate that RSD may be caused or mediated by non-organic factors. Unfortunately, there have been few studies using standardized measures of mood and illness behavior that have compared patients with RSD to patients with other chronic pain disorders. The goal of the present study, therefore, was to compare the pattern of psychological dysfunction in patients with RSD to the pattern of dysfunction in patients with chronic back pain and local neuropathic pain. Patients with back pain resemble those with RSD in that both may report symptoms that cannot be reconciled with objective physical findings. Patients with local neuropathy, by contrast, report pain that is both circumscribed and consistent with a known organic cause. The records of 253 patients attending a tertiary pain service were retrospectively reviewed and three distinct (non-overlapping) diagnostic groups were formed: 25 were assigned to the RSD group; 44 to the back pain group; and 21 to the local neuropathy group. Using a set of stringent criteria to diagnose RSD and an analysis of covariance to control for differences in symptom duration and age, the present study found no evidence to suggest that patients with RSD were psychologically unique. Instead, RSD patients were remarkably similar to those with local neuropathy in terms of their symptom reporting, illness behavior, and psychological distress. The only exception was that RSD patients had more disability days during the preceding 6 months than those with local neuropathy ( P<0.05). The back pain group, on the other hand, presented with more diffuse pain complaints ( P<0.05) and had a greater number of non-specific medical symptoms ( P<0.05) compared to either the RSD or local neuropathy group. In contrast to previous research using less stringent diagnostic criteria, there was no evidence of higher pain scores or lower levels of psychological distress among patients with RSD. In addition, a validated survey of childhood trauma found that sexual abuse, physical abuse, emotional abuse, and cumulative trauma were evenly distributed among all three diagnostic groups. The burden of proof would appear to be upon those who advocate the non-organic hypothesis to provide credible evidence of psychological involvement in the etiology of RSD.

Quantitative evaluation of sympathetic nervous system dysfunction in patients with reflex sympathetic dystrophy

The sympathetic nervous system function in 20 patients with reflex sympathetic dystrophy (RSD) of one upper extremity was examined by a non-invasive laser Doppler method to assess fingertip blood flow and vasoconstrictor response to deep inspiration. We observed an increased blood flow but an unchanged vasoconstrictor response in the affected hand in stage 1 of the disorder, but in stage 2 there was a decreased blood flow and a stronger vasoconstriction following an inspiratory gasp. Skin blood flow and vasoconstrictor response returned to normal following successful treatment of the condition. These results suggest that in RSD patients the sympathetic nervous system function is altered and is different in the various stages. The objective method used in our study may be of value in the diagnosis and management of RSD.

Evaluating treatments of RSD

W henever two or three pain doctors are gathered together, there is a high probability that the conversation will drift to reflex sympathetic dystrophy (RSD). I think the reasons are that we all see RSD patients, there is a tantalizing link between our needle therapies and improvement, and in the absence of evidence opinion holds sway-ideal fertile ground for conversation. Tanelian's focus article highlights some of the areas of ignorance:

Psychological differences between reflex sympathetic dystrophy and non-RSD chronic pain patients

This study examined possible psychological differences between Reflex Sympathetic Dystrophy (RSD) and non-RSD chronic pain patients. Unlike the few previous studies in this area, this study controlled statistically for age and pain duration differences across diagnostic groups, and included a non-RSD limb pain control group. Subjects were a consecutive series of 34 RSD, 50 non-RSD limb pain (Limb), and 165 low back pain (LBP) patients presenting for treatment at the Rush Pain Center. Analyses revealed that RSD patients reported more somatization and phobic anxiety on the Brief Symptom Inventory than LBP patients. RSD patients also reported greater coping with pain through diverting attention than LBP patients did on the Coping Strategies Questionnaire. Comparisons between the RSD and Limb groups revealed no significant differences with the exception of somatization scores. The relationship between distress and pain severity was found to be stronger in RSD and Limb patients than in LBP patients. These results provide partial support for clinical assumptions that RSD patients are more psychologically dysfunctional than other chronic pain patients. However, these conclusions do not generalize across all comparison groups. The fact that RSD and non-RSD limb pain patients were quite similar on nearly all measures suggests that sympathetic mediation of pain is not the source of these psychological differences.